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Hesi Fundamentals Test Questions and Complete Solutions Graded A+
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Hesi Fundamentals Test Questions andComplete Solutions Graded A+
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the
underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?
1
Stage I
2
Stage II
3
Stage III
4
Unstageable - Answer: 4
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the
wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break
in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the
epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow
crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone,
tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a
medication reconciliation is completed? Select all that apply.
1
After reporting severe pain
2
On admission to the hospital
3
Upon entering the operating room
4
Before transfer to a rehabilitation facility
5
,At time of scheduling for the surgical procedure - Answer: 2, 4
Medication reconciliation involves the creation of a list of all medications the client is taking and
comparing it to the health care provider's prescriptions on admission or when there is a transfer to a
different setting or service, or discharge. A change in status does not require medication reconciliation.
A medication reconciliation should be completed long before entering the operating room. Total hip
replacement is elective surgery, and scheduling takes place before admission; medication reconciliation
takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of
the following laboratory values?
1
White blood cell (WBC) count of 15,000 mm3
2
Negative protein in the urine
3
Blood urea nitrogen (BUN) of 20 mg/dL
4
Prothrombin of 12.0 seconds - Answer: 1
White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000
mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal
values.
Often when a family member is dying, the client and the family are at different stages of grieving. During
which stage of a client's grieving is the family likely to require more emotional nursing care than the
client?
1
Anger
2
Denial
3
Depression
4
,Acceptance - Answer: 4
In the stage of acceptance, the client frequently detaches from the environment and may become
indifferent to family members. In addition, the family may take longer to accept the inevitable death
than does the client. Although the family may not understand the anger, dealing with the resultant
behavior may serve as a diversion. Denial often is exhibited by the client and family members at the
same time. During depression, the family often is able to offer emotional support, which meets their
needs.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease.
Which foods would be appropriate to include in the teaching plan? Select all that apply.
1
Whole grains
2
Cooked fruit and vegetables
3
Nuts and seeds
4
Lean red meats
5
Milk and eggs - Answer: 1,2,5
With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the
fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no
fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are
contraindicated as they may be retained and cause inflammation and infection, which is known as
diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee.
What should the nurse include in the pain assessment? Select all that apply.
1
Pain history, including location, intensity, and quality of pain
2
, Client's purposeful body movement in arranging the papers on the bedside table
3
Pain pattern, including precipitating and alleviating factors
4
Vital signs such as increased blood pressure and heart rate
5
The client's family statement about increases in pain with ambulation - Answer: 1,3
Accurate pain assessment includes pain history with the client's identification of pain location, intensity,
and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes
time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet
the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and
determine it cause. Purposeless movements such as tossing and turning or involuntary movements such
as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and
heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and
therefore the nurse has to ask the client directly instead of accepting statement of the family members.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the
nurse take?
1
Immediately stop the infusion.
2
Lower the height of the enema bag.
3
Advance the enema tubing 2 to 3 inches.
4
Clamp the tube for 2 minutes, then restart the infusion. - Answer: 2
Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema
solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to
the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing
the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion
may be attempted if slowing the infusion does not relieve the cramps.
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